Why “Painless Dentistry” Doesn’t Have to Be An Oxymoron

Dentistry has got a bad reputation!

“No offense doc but I hate dentists.” …said everyone who ever came to see me.
“I was in Vietnam and I’d rather be shot at than come see you.” …said one of my veteran patients.
“My last dentist put his foot on my chest and pulled a tooth out while I wasn’t numb!” …said most people who ever had a tooth extracted.

Why so much hate? In my personal experience, most of the people who hate dentists have had really bad experiences in the past. They’ve got legitimate reasons to be fearful. As a profession, we dentists, especially in years past, haven’t done a great job with pain and anxiety management. Uncontrolled pain and anxiety creates lifelong dental phobics.

So here’s the secret… While dentistry isn’t ever something that will be fun, it doesn’t have to be the traumatic experience that many people expect. Dentists have a huge number of different tools at their disposal to make dentistry as painless and easy as possible. For the most part, all it takes is a willingness to listen to a patient’s fears and address them with whatever tool is most appropriate.

What?!? We have more options than just “Open wide”, “It’ll only pinch a bit” and “Suck it up”? Yes! I’m going to cover all your options here, from techniques that have been around forever, to the latest advances in painless dentistry.

If you’re a dentist who thinks all dental phobics are over-dramatic and that the previous statements are appropriate, this article may not be for you. You should probably go hang up your drill and find a job that doesn’t require contact with the public. I hear dental insurance companies are always looking for cranky dentists to deny claims. Everyone else, let’s get working on ways to make dentistry better for our patients!

Old School

Let’s start with some options that have been around for a long time. Just because these options are technically “old school” doesn’t mean they shouldn’t be used. It’s my opinion they should be used far more often than they currently are today.

Laughing Gas / Nitrous Oxide
Laughing gas is almost synonymous with going to the dentist but somehow many dentists don’t offer this at all. I’ve heard from many that they find it to be too much hassle. I’ve had the exact opposite experience in my practice. The benefits of laughing gas include decreased anxiety, increased pain tolerance, quick acting effects, and an almost perfect safety profile compared to any other type of sedation. The downsides… ummm…. occasionally people don’t like how it feels and we have to stop using it. So why aren’t more dentists using laughing gas? Beats me. It is the absolute easiest and quickest way to make a dental appointment easier. I often give it away free because it makes the appointment easier for me and the patient. Easier for me + Easier for the patient = A good day!

Sedation
Sedation can range from taking an oral medication before a dental appointment (with or without nitrous oxide) all the way up to IV sedation or general anesthesia. Of all the techniques we go over here, this is by far the most challenging to get trained in and implement due to safety and liability issues with sedation. It is also the most effective option for treating patients who are truly terrified of any type of dental experience. If you’re able to offer this safely and effectively, you’ll really set yourself apart. One option for sedation if you don’t want to go through training is to look for a traveling anesthesiologist who comes to your office and does sedation while you do the dental work. This is a fantastic option where you can focus exclusively on treating your patient instead of worrying about anesthesia at the same time. There are more and more anesthesiologists who offer services like this today. If you’re especially lucky, you might even find a dental anesthesiologist who understands the special challenges that come along with sedating a patient for dental work (dental work is essentially an anesthesiologists worst nightmare).

Air Abrasion
Air abrasion uses a high pressured jet of abrasive particles to conservatively remove smaller to medium sized decay in teeth. As it doesn’t generate any vibrations, pressure, or heat most people don’t need any shots of anesthetic (yay!) to have the procedure done. Many people think air abrasion is a new technique in dentistry. It actually has been around over 60 years! Early on, it wasn’t something that was typically used because the bonding materials needed to do minimally invasive dentistry weren’t invented yet. Now that we’ve got all these great bonding techniques, somehow air abrasion still isn’t routinely used. Very few dentists own an air abrasion device and even less use it routinely. It can be especially useful on children as it is far less “scary” than a dental drill and doesn’t require a shot! Kids who have good dental experiences are far less likely to become dental phobics in the future.

New-Fangled Stuff

Distractions
I spent about $400,000 several years ago to build a brand new office. You know what makes the biggest impression on our patients? It sure isn’t the $50k panoramic machine, several thousand dollar chairs, or amazingly efficient layout. It is the $300 television mounted on the ceiling that they can watch during treatment while wearing a pair of noise canceling headphones. OK, OK so televisions aren’t exactly new to the scene. CHEAP flat screen televisions sure are though. I just saw a 37 inch TV at Best Buy the other day for about $150. This is what most dentists charge for a single filling. Considering the benefits, calling it an affordable investment is an understatement. I’ve found it to be equally effective for both adults and children.

Vibraject™ / DentalVibe™
The Vibraject™ and DentalVibe™ play off our overall distraction theme. These devices vibrate a patient’s lip while the injection is being given in order to distract them from the sensation. They’ve been proven to be quite effective and many dentists say they wouldn’t want to give injections without them anymore. If you’re talented you can pull off this trick yourself without the device. Just vibrate a patient’s cheek quickly while giving the injection. Dentists have used this technique successfully for a long time. That is about the only thing I remember about the dentist from when I was a child.

Compounded Topical Anesthetic
Topical anesthetic has been used for a long time to reduce the pain associated with the needle stick. Unfortunately the only topical anesthetic that is widely available is 20% benzocaine. This works OK but there are a lot better options out there. The downside… you have to get them specially compounded at a pharmacy. It’s unbelievable that none of the big dental companies have come up with a better topical anesthetic (OK I do actually know why… The FDA approval process is a bureaucratic nightmare and costs a fortune for approval of a new formulation). If anyone in dental product R&D is reading this, I’D BUY A BETTER TOPICAL IN A HEARTBEAT! Get working on it!

My favorite formulation is a compounded gel with 10% lidocaine, 10% prilocaine, and 4% tetracaine. A SMALL dab of this a couple of minutes before an injection does wonders to almost entirely eliminate the pinch of the needle stick.

There are a good number of other formulations but most are some variation of these anesthetics. Some compounding pharmacies offer to add 2% phenylephrine to the gel to prevent but I do not recommend this. Any of these gels with phenylephrine seems to cause high incidence of tissue sloughing in the area where the gel was applied. I’ve only rarely seen minor tissue sloughing with the plain mixture of anesthetics. Once you use compounded topical you’ll never want to go back to plain benzocaine again!

Buffered Anesthetics
Even if the needle stick during a shot is totally painless, the shot can still hurt. Why is this? Most anesthetics used in dentistry are quite acidic. When they are injected they cause quite a burning sensation. This sensation can be minimized by injecting very slowly but people will still occasionally feel it. A couple of years ago a system known as Onset™ was introduced that buffered the anesthetic with sodium bicarbonate in order to bring it up to a more neutral pH level. Buffering solutions is commonly done in medicine but really hasn’t been used in dentistry up to this point. When anesthetic is injected with a pH close to physiologic levels, the burning sensation is almost entirely eliminated. In addition to reducing the burning it also dramatically increases the speed that the anesthetic takes effect. Mandibular blocks are fully complete within a minute and a half. You don’t even have to leave the room before getting started. There are a couple of other buffering systems that have come out since then but Onset™ remains the standard.

Stanley Malamed (You know, the guy who basically wrote the book on dental anesthesia) is a big fan. You should be too!

The Wand™
The Wand™ is a computerized anesthesia device that injects anesthetic at a controlled rate. As we discussed with buffered anesthetics, the rate at which anesthetic is delivered determines whether that uncomfortable burning sensation is felt. The Wand™ keeps this from happening by injecting at an extremely slow and controlled rate that is controlled by a computer, instead of your hand. Interestingly enough, the slow injection rate also provides higher success rates of getting people numb. One additional benefit to The Wand™ is that it looks far less scary than a typical dental syringe. Perception counts for a lot in how pain is experienced. The Wand simply looks like it will hurt less.

Lasers
Lasers are very slowly making headway into dental offices. They can be used to remove tooth structure, oftentimes without any need for an injection. Due to how the laser pulses it actually induces some analgesia in the nerve of the tooth. It is truly needle free dentistry. There are some major downsides with lasers at this point. They can’t remove all types of materials from a tooth like a dental drill can, there is a huge learning curve, major magnification is required, and lastly the units still are wildly expensive (think $100kish). When the price comes down, I think they’ll start showing up in more dental offices but I don’t expect them to replace dental drills anytime soon.

Kovanaze™
Kovanaze™ is the first needle free anesthetic option that I know of. Kovanaze™ was approved in the summer of 2016 by the FDA for use as a dental anesthetic and became available for purchase towards the end of the year. Kovanaze™ is a combination of the anesthetic tetracaine and oxymetazoline. This solution is sprayed up the nostril and provides anesthesia from the premolars to central incisor on the same side. Second premolars have a success rate around 64% while the first premolar through central incisor have a success rate of 96%. For major anterior work, such as veneers, this is a game changer. I know that I personally hate giving injections for the maxillary anterior teeth due to the sensitivity of the tissues in this area, especially around the centrals. Going from multiple painful injections to several painless nasal sprays makes these procedures far easier and essentially painless for patients.

The big downside at this point is cost. As of the time of this writing it costs approximately $600 for 30 sprays (or 15 doses as each dose requires two sprays). This is cost prohibitive for routine use by most dentists. Hopefully the price will start to come down and it will come into more routine use in practice. This would be a huge win for patients in general. Injections don’t bother me that much and I’d still pay extra just to have this type of anesthesia. My guess is that I’m not the only one.

As cool as needle free anesthesia is, the real story I’d like to hear is how the inventor originally came up with the idea of nasal spray anesthesia. Also, who was the unlucky person to be the original test subject?!?

There are so many different options out there for making dental care easier for patients. Not all of them have to be difficult or expensive. I’d highly recommend that you pick just one of these tools to implement well in practice and see what a difference it can make. Even better, pick several that you don’t currently offer and put them in place. I believe that comfortable patients will be happier, trust us more, and follow through with treatment which is ultimately a win-win for everyone.

About the Author:
I’m Dr. M, a regular dentist with aspirations of being a tooth saving superhero. My website, The Healthy Mouth Project is dedicated to educating and equipping patients to take control of their oral health.

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DentalBuzz explores rising trends in dentistry with its own slant. The speed at which new products and ideas enter the dental field can often outpace our ability to understand just exactly the direction in which we are heading. But somehow, by being a little less serious about dentistry and dental care, we might get closer to making sense of it all.

So yeah, a tongue-in-cheek pun would fit really nicely here, but that would be in bad taste. Never mind, it just happened anyways. Stop reading sidebars already and click on some content instead.

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